Not all devices that measure the same property do it in the same way—a clock might use a spring system or it might be digitally synchronized to a transmitted signal. Although both have the same goal of reporting accurate time, each is subject to different errors. Sometimes even the same device uses different systems to measure the same property. A relatively simple device like a camera will use one sensor system to capture light intensity for an image and a second sensor to capture light intensity for making automatic adjustments of aperture and flash. It does not seem outlandish, therefore, that the brain might also have developed multiple sensory systems to achieve different goals. Indeed, an influential hypothesis has argued that people use two separate visual processing systems in much the same way as a camera—one for creating our perception of the world and another for guiding our actions within it.One line of evidence supporting this dual hypothesis comes from an illusion known as Roelofs effect. Usually, people are pretty good at judging the location of even a small object. But if the small object is surrounded by a large frame and the frame itself is not centered in front of the person who is judging it, the viewer will perceive the object as shifted in a direction opposite that of the frame. This may not in itself be surprising, but the same person who perceives an offset of the object where none exists is nonetheless able to grasp it without difficulties.PLoS Biology, Paul Dassonville and his colleagues reexamine the seeming dissociation of visual analysis for perception and action, and call it into question. Through a careful quantitative analysis of the conditions under which the Roelofs effect occurs, they find that it traces not to an illusory perception of the object location but to an illusory perception of self. The large frame, presented under experimental conditions in which subjects sit in darkness without access to a normal rich sensory environment, actually causes people to incorrectly perceive their own centers as rotated towards the frame and therefore to conclude that the small object is offset with respect to themselves. This may seem like a subtle distinction, and yet, since it is the observer's frame of reference that is altered, that same distorted frame of reference will be used to guide movement. Thus, the error in movement planning should cancel the error in perception, and people should have no trouble reaching for the object despite their misperception, which is indeed what is observed.In this issue of Others have questioned the hypothesis that two separable neural systems process the visual world for perception and action, but this study removes one of the strongest pieces of evidence in its favor with a precise alternative explanation. No two brains may see the world identically, but the authors suggest that it may be time to concede that a single brain, at least, has the same world view.


In Finland, dental services are provided by a public (PDS) and a private sector. In the past, children, young adults and special needs groups were entitled to care and treatment from the public dental services (PDS). A major reform in 2001 – 2002 opened the PDS and extended subsidies for private dental services to all adults. It aimed to increase equity by improving adults' access to oral health care and reducing cost barriers. The aim of this study was to assess the impacts of the reform on the utilization of publicly funded and private dental services, numbers and distribution of personnel and costs in 2000 and in 2004, before and after the oral health care reform. An evaluation was made of how the health political goals of the reform: integrating oral health care into general health care, improving adults' access to care and lowering cost barriers had been fulfilled during the study period.National registers were used as data sources for the study. Use of dental services, personnel resources and costs in 2000 (before the reform) and in 2004 (after the reform) were compared.In 2000, when access to publicly subsidised dental services was restricted to those born in 1956 or later, every third adult used the PDS or subsidised private services. By 2004, when subsidies had been extended to the whole adult population, this increased to almost every second adult. The PDS reported having seen 118 076 more adult patients in 2004 than in 2000. The private sector had the same number of patients but 542 656 of them had not previously been entitled to partial reimbursement of fees.The use of both public and subsidised private services increased most in big cities and urban municipalities where access to the PDS had been poor and the number of private practitioners was high. The PDS employed more dentists (6.5%) and the number of private practitioners fell by 6.9%. The total dental care expenditure (PDS plus private) increased by 21% during the study period. Private patients who had previously not been entitled to reimbursements seemed to gain most from the reform.The results of this study indicate that implementation of a substantial reform, that changes the traditionally defined tasks of the public and private sectors in an established oral health care provision system, proceeds slowly, is expensive and probably requires more stringent steering than was the case in Finland 2001 – 2004. However, the equity and fairness of the oral health care provision system improved and access to services and cost-sharing improved slightly. Finland has two parallel systems for delivering dental care. They are the Public Dental Service (PDS) and private services. The PDS was established in 1972 to ensure the provision of dental services in sparsely populated areas  and an improved national economy.Against this background, the aims of this study were to assess the impact of the oral health care reform, introduced in 2001–2002, on the utilization of publicly funded and private dental services, numbers of oral health care personnel and costs at both regional and national levels in 2000 and 2004, before and after the oral health care reform, using available data. The study also included an evaluation of how the health political goals of the reform: integrating oral health care into general health care, improving adults' access to care and lowering cost barriers had been fulfilled during the study period.In Finland, data for oral health care provided, oral healthcare workforce numbers and costs are reported at both municipal and national levels and then recorded in national registers -7, whichThe PDS and NHI data were classified according to the size and extent of urbanisation  and by g• the ten biggest cities (population over 75 000),• other urban municipalities (with at least 90% of population living in urban settlements or the population of the largest settlement with at least 15 000 inhabitants),• semi-urban municipalities (with 60–90% of the population in urban settlements and the population of the largest settlement of 4 000 – 15 000 inhabitants)• rural municipalities.Geographically the data were divided into 5 groups corresponding with the University hospital regions Figure . Data onComparisons were made between the PDS and private services in 2000 and in 2004, regarding numbers of patients, numbers of care providers ,7 and chIn 2000, when access to publicly subsidised dental services for adults was restricted to those born in 1956 or later, every third adult had used the PDS or subsidised private services  was highest in East Finland and lowest in South Finland (p < 0.001). After the reform, the use of services was significantly lower in the North (p < 0.001) than in the other regions (p < 0.001) Figure . In all The utilisation of the PDS increased most in big cities and other urban municipalities (2.6 – 2.9%-units) where previously use had been lowest Table . The useThe total number of working-age dentists (under 63 years) fell by 247 (5.3%) from 2000 to 2004. The PDS employed 131 dentists (6.5%) more and the private sector 143 dentists (6.9%) fewer after the reform. Population per dentist ratio increased from 1076 to 1146. The number of dental hygienists increased from 1022 to 1262 (23%) and population per dental hygienist ratio decreased from 5040 to 4122. No big changes occurred in the numbers of dental assistants and technicians.The regional differences in the distribution of dentists did not change between 2000 and 2004. Thus in both 2002 and 2004, 66–68% of the public dentists and 80% of the private dentists worked in the three southernmost University hospital regions Figure . The popThe total dental care expenditure (PDS plus private services) increased by 21% from 2000 to 2004 (from EUR 584 million to EUR 708 million)  and municipalities (80%) did not change. In the private sector the National Health Insurance financed a bigger part of the costs  and the patients' personal payments (out of pocket costs) decreased from 85% to 74% over the four year period.Patients' payments were the largest source of oral health care funding before the reform in 2000, accounting for 55% of total cost of oral care. After the reform, in 2004, patients funded slightly less than half of the costs of all oral care (49%). Local authorities funded 37% of the costs in 2000 and 38% in 2004 through municipal tax revenues and the state support to the municipalities. The NHI funded the remaining balance of 8% in 2000 and 13% in 2004  higher than public fees. The results of a questionnaire study conducted in 2004, suggested that the increase in use of subsidized dental services was greatest in amongst those with a middle level of education . Before Routine register data was used in this study. As dentists' remuneration in the PDS is partly based on these data and private patients' reimbursements by the NHI are fully based on recorded treatment, data on utilisation of dental services can be considered to be comprehensive in both sectors. One limitation was that because fewer than half of the adults treated in the private sector who were entitled to reimbursements only for reimbursable treatments, the total number of patients treated in the private sector had to be estimated. In 2000, fewer than half of the adults were entitled to such reimbursements whereas in 2004, all adults were entitled to reimbursements (except those who received a prosthetic care in the private sector). However, as few adults were likely to have received prosthesis without prior clinical examination or other treatments, which were eligible for partial reimbursement, a very small number would not have been recorded in the registers in 2004. A further potential complication in our estimates was that the PDS does not separate costs for the treatment of children and those for adults.The oral health care reform was considered politically so important that the Parliament passed the changes more rapidly than proposed by the Ministry of Social Affairs and Health which supervises the health care provision system. In a period of two years (2001 to 2002) 2.1 million adults (40.9% of the population), who had previously not been eligible, became eligible for Public Dental Services or subsidised private care. During the four years covered in this study, there was little guidance for the PDS on how to proceed with the implementation of the reform. According to the chief dentists in the PDS, the main priorities were recruiting new dentists and hygienists and delegating to dental hygienists tasks previously done mainly by dentists . HoweverThis study shows that there was a small increase in the supply of oral care services between 2000 and 2004. However, the mean number of patients seen in one year by a dentist in the PDS decreased from 863 to 840. On the other hand, the numbers of dental hygienists increased and they provided a greater proportion of children's treatments in the PDS than before . In the The chief dentists in the PDS complained that their dental staff did not support the speed of the reform. In particular, the changes required in work routines were often opposed locally . There wA special survey conducted on treatments provided in the PDS in 2003 showed that a third of the adult patients had made emergency visits to a dentist . This mai.e. the public sector catering for children, younger adults and special needs groups and the private sector for well-off middle-aged or older adults [The reform considerably increased the total running costs of oral health care. However, it should be noted that reducing costs and increasing efficiency were not primary goals of the reform. In 2004, the public sector saw 842 947 children and 964 214 adults  at a lower cost than the private sector which saw just over one million adults. The traditional distribution of the patients (r adults ), probabThe average rise in prices in the private sector between 2000 and 2004 was about 20% and the total NHI support for basic care provided by the private sector rose by 26% . Thus, iIn most OECD countries, considerable inequities exist in general health care . The FinThe results of this study indicate that implementation of a substantial reform, that changes the traditionally defined tasks of the public and private sectors in an established oral health care provision system, proceeds slowly, is expensive and probably requires more stringent steering than was the case in Finland 2001 – 2004. However, the equity and fairness of the oral health care provision system improved and access to services and cost-sharing improved slightly.The author(s) declare that they have no competing interests.TeN: Principal investigator, collected data, performed statistical analyses, and wrote the manuscript.EW: Main supervisor, designed the study, and wrote the manuscript.TaN: Participated in the design of the study, collected data, and performed statistical analyses.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Occasionally infection of an algal cell by an individual particle fails and the viral DNA is dynamically ejected from the capsid. This shows that the release of the DNA generates a force, which can aid in the transfer of the genome into the host in a successful infection. Imaging of ejected viral DNA indicates that it is intimately associated with proteins in a periodic fashion. The bulk of the protein particles detected by atomic force microscopy have a size of ∼60 kDa and two proteins (A278L and A282L) of about this size are among 6 basic putative DNA binding proteins found in a proteomic analysis of DNA binding proteins packaged in the virion. A combination of fluorescence images of ejected DNA and a bioinformatics analysis of the DNA reveal periodic patterns in the viral DNA. The periodic distribution of GC rich regions in the genome provides potential binding sites for basic proteins. This DNA/protein aggregation could be responsible for the periodic concentration of fluorescently labeled DNA observed in ejected viral DNA. Collectively the data indicate that the large chlorella viruses have a DNA packaging strategy that differs from bacteriophages; it involves proteins and share similarities to that of chromatin structure in eukaryotes.Chlorella viruses have icosahedral capsids with an internal membrane enclosing their large dsDNA genomes and associated proteins. Their genomes are packaged in the particles with a predicted DNA density of ca. 0.2 bp nm Phycodnaviridae have a long evolutionary history possibly dating back to the time when eukaryotes arose from prokaryotes Chloroviruses in the family PBCV-1 virions, the prototype chlorovirus, are large icosahedral particles  that have an internal lipid bilayered membrane C. variabilis to initiate infection. The PBCV-1 spike first contacts the host cell wall + channel (named Kcv) predicted to be located in the internal membrane of the virus, followed by rapid release of K+ from the cell + and associated water fluxes from the host reduce its turgor pressure, which may aid ejection of viral DNA and virion-associated proteins into the host PBCV-1 infection resembles infection by tailed bacteriophages because its genome must cross the cell wall (and membrane) of its host −3. This value approaches the maximal theoretical density for DNA packaging and the DNA is almost at crystalline density inside the phage head −3−3.A property that all NCLDVs including the chloroviruses share with dsDNA bacteriophages and other DNA viruses is that they package a dsDNA genome into a geometrically confined capsid. An example of DNA packaging is the 48.5 kb genome of bacteriophage λ. Its extended linear form of 16.5 µm DNA packaging density has implications for virus infection. Experiments and theoretical calculations indicate that the high DNA packaging density in phages generates enormous internal pressure in the particles ranging up to 50 bars PBCV-1 is unique among the NCLDVs in that it uncoats its DNA at the cell surface and leaves an empty capsid on the outside of the cell wall, similar to many tailed bacteriophages. Consequently, PBCV-1 may use similar mechanical forces to eject its genome into its host cell as phages PolyomaviridaePapillomaviridaeAdenoviridae, Asfarviridae, Baculoviridae) express small arginine rich protamine-like proteins with putative DNA condensation functions Phage DNA packaging depends primarily on two parameters, the function of motor proteins and cations. Dense packaging of DNA requires that 90% of its charge is neutralized Currently little information is available on the mode of DNA packaging in the large chloroviruses. At least in the case of PBCV-1, and presumably the other chloroviruses, DNA neutralization may also employ proteins because PBCV-1 virions contain 148 different viral-encoded proteins , some of which have been described as DNA-binding proteins C. variabilis cells with a high m.o.i. . Under these conditions it occurs as if the DNA is released from the virus particle but not able to enter the host; as a consequence the particle is dynamically catapulted away from the host cell leaving an unraveled, quasi-linear DNA polymer tethered to the cell. In some images it is possible to see the capsid at the end of the DNA thread projected away from the host (data not shown). The reason for the release of DNA into the medium is not known. However we know from other studies that usually only one virus infects the host cell, while the remaining viruses are excluded Phage DNA release is often triggered by an interaction between phage tails and host receptor. This interaction causes the DNA to rapidly expand and the DNA catapults out of the capsid This release of DNA into the medium must be fast because it is possible to detect isolated DNA molecules already within 5 min post infection. C. variabilis cell with the typical hole in the wall, which a virus digests in the course of infection. From this location two linear structures project away from the host in an angular fashion. The projecting structures are most likely unfolded viral DNA because the half width of their cross section is <10 nm. The combination of electron microscopic and fluorescent images suggests that PBCV-1 DNA might not in all cases enter its host initially by either of its termini. This scenario would suggest that packaging of the DNA in the virion differs from ejection because it is unlikely that DNA packaging begins in the middle of the genome.Frequently we observed two DNA strands under the same conditions, which projected away from the host at a common point of origin . This phClose scrutiny of the fluorescently labeled ejected PBCV-1 DNA suggests it is structured. The images indicate: i) a non-uniform distribution of DNA and ii) loops in the DNA polymer. Images of ejected DNA at higher magnifications indicate that the fluorescence associated with the DNA exhibits distinct maxima. In regions where the fluorescence signal was well resolved the intensity maxima were quasi periodic . In thisThe structured pattern seen with PBCV-1 DNA does not occur in fully ejected DNA from phages λ or T5; the phage DNAs fluoresce homogeneously along the axis of the extended polymer In addition to these periodic domains of concentrated DNA, we occasionally detected another higher order organization in the PBCV-1 DNA strands ; in thisCollectively, the data suggest that PBCV-1 DNA is stored inside the capsid in an ordered fashion. This structure includes a periodic formation of folds and on a larger scale a formation of loop structures. These loop structures probably open up during the ejection and are hence observed only in rare cases.To obtain more information on PBCV-1 DNA structure we viewed the isolated DNA by AFM. For these experiments PBCV-1 particles were osmotically shocked and subsequently transferred with the emerging content onto fresh mica for imaging. This procedure separates proteins that are tightly bound to DNA from those that are free. Association of DNA with proteins was reported in a previous AFM study on ruptured PBCV-1 particles A comparison between images of PBCV-1 DNA shows that proteins associated with DNA in AFM images produce a different periodic pattern than the fluorescence images. The reason for this difference in DNA/protein association is probably related to the isolation method. The image in 3 (435 measurements) and 66.4±0.09 nm3 (652 measurements), respectively. Measurements of 711 randomly chosen protein particles associated with the disrupted virus produced a mean volume of 60.3±0.09 nm3. These experiments suggest that the PBCV-1 DNA particles are associated with a protein(s) in the range of ca. 60 kDa. The resolution of the images does not allow one to distinguish between monomers of a 60 kDa protein or multimers of smaller proteins.To estimate the size of the proteins associated with PBCV-1 DNA, we imaged the volume of a large number of DNA associated protein particles ; this isTo estimate the ratio of proteins that associate with DNA from the virus particles, we measured the length of the DNA molecule versus the number of total proteins in 5 images e.g., . For thi−10) and one match in the decoy database occurred with a protein score of 48 (cutoff of 43). From the spectra, 9 viral proteins were identified with a significance of p<0.05  and estimated the most abundant proteins in the particle using the exponentially modified protein abundance index (emPAI) algorithm The periodic pattern of isolated DNA bands reported in According to the distribution of Fourier-amplitudes , the mosThis protocol has an additional advantage because it can conceptually reveal periodicities of much larger motifs; e.g., consider the simple case of two motifs separated by some variable genomic region. Separately these two motifs would each exhibit the same periodicity. If we analyze the data averaged over all motifs, however, we also reveal the “synchronization” of the motifs along the chain and therefore the correlated periodicity.To verify our results and to demonstrate the robustness of our protocol we repeated the analysis using a strict criterion: an exact match between the motif without wildcard characters and the genomic fragment. As mentioned in the The present results suggest that chlorovirus PBCV-1, like their eukaryotic hosts, neutralize their DNA with DNA binding proteins. The data are consistent with a model in which the viral genome has an inherent pattern with periodically spaced GC rich regions, which provide interactive sites for DNA binding proteins. DNA is presumably wound around the respective basic proteins for neutralization and packaging. The interaction results in the isolated DNA containing periodic thickenings; a higher order of organization may also involve small loops, which contribute to packaging DNA and/or gene regulation. The robust aggregation of the DNA with proteins also favors a stable structure for the virus DNA when it is ejected into the cytosol of the host, where the cation concentration is reduced Chlorella NC64A (recently named Chlorella variabilisC. variabilis cells were inoculated in MBBM containing 30 µM DAPI with the fluorescently labelled PBCV-1 at a multiplicity of infection (m.o.i) of ∼100 10 PFU/ml) was incubated for 1 h in 0.5 M KCl solution and then rapidly transferred to 60 mM KCl. For microscopic imaging experiments, the DNA was then labelled by adding 30 µM DAPI to this solution. For other experiments, we transferred the particles to fresh mica for atomic force microscopy (AFM) imaging or kept the diluted solution for 1 h before separating the soluble proteins from the released DNA according to PBCV-1 particles and ejected fluorescently-labelled DNA were imaged on a Zeiss Axioskop 40™epifluorescence microscope. Samples were excited at 358 nm and fluorescence detected through a 461 nm filter. The images were recorded with a sensitive electron multiplying charged coupled device and a digital camera Andor LUCA™.Images of ejected DNA were obtained with an AFM  using a cantilever  with a <10 nm tip. Fifty µl of a solution containing PBCV-1 particles or viral DNA (10 ng/µl), which was released from the capsids by osmotic shock, were incubated for 5 min on a smooth mica surface. The preparation was washed twice with 1 ml distilled water and dried by high air pressure . For imaging, the tapping mode was used which reduces sample exposure. The volume of particles was analysed using the particle analysing tool Image Processing Software, Image Metrology A/S with standard settings.N, where N is the motif length. Any periodic or semi-periodic structures in this data are revealed by Fourier analysis as peaks in the Fourier components. We restricted our analysis to small motifs because of computational constraints. Therefore, we could not detect signals for larger motifs directly, e.g., two binding motifs connected by a highly variable region. This prompted us to not look for one particular motif with the most pronounced peak in the Fourier spectrum. Instead, we counted how often a particular length scale appeared, averaged over all motifs. This protocol has an additional advantage because it also reveals periodicities of much larger motifs; e.g., consider the simple case of two motifs separated by some variable genomic region. Separately these two motifs would exhibit the same periodicity. If we analyze the data averaged over all motifs, however, we also uncover the “synchronization” of the motifs along the chain and therefore the correlated periodicity. We also analyzed the motifs that contributed most, for their relative content of nucleotide types.The experimental results indicated that one or more DNA binding proteins were involved in organizing the viral DNA in nearly equidistant units; if so, the mechanism would most likely require periodic binding motifs in the DNA. To identify protein-binding domains in PBCV-1 DNA we analyzed its genome sequence for periodic signals using our own code C. variabilis and PBCV-1 virus. Additional search parameters were set to monoisotopic mass, charge 1+, maximum of 1 missed cleavage, peptide tolerance of 0.3 m/z and p<0.05. The root mean square (RMS) errors on the peptide mass matches ranged from 21–102 ppm. As a control, all searches were repeated using the decoy database generated by the Mascot Server software, using the same settings. In some cases, high energy CID MS/MS sequencing of the peptides was employed (using the same samples and instrumentation) to confirm protein identification.In a further analysis we separated DNA bound proteins from the re-suspended pellet by SDS PAGE. Peptide map fingerprinting (PMF) of proteins from SDS-PAGE gel slices was performed using standard procedures, with treatment of the proteins with dithiothreitol and iodoacetamide followed by trypsin digestion. Peptides eluted from the gels were purified on ZipTip C18 columns (Millipore) and applied to a stainless steel target together with α-cyano-4-hydroxycinnamic acid as a matrix. The peptides were analyzed in a reflectron mode using a Shimadzu Biotech Axima Performance MALDI-TOF mass spectrometer. Calibration was via nearest neighbor external standards, using 8 peptides (Sigma Aldrich) with m/z from 757.4 to 3657.9. Mass lists from the individual PMF spectra were submitted to an in-house Mascot Server PMF search engine using the NCBInr database. The taxonomy was limited to The virus was purified essentially as described previously Nobserved/Nobservable−1). We assumed the major capsid protein (A430L) is present in 1440 copies per virion for these calculations and other protein abundances were estimated from this value.Virion proteins were evaluated essentially as described Bioinformatics Analysis S1Application of Fast-Fourier-Transformation (FFT) protocol for detecting potential periodicities of binding motifs in the genome of dsDNA virus PBCV-1.(DOC)Click here for additional data file.


The monotonicity of the solutions of a class of nonlinear fractional differential equations is studied first, and the existing results were extended. Then we discuss monotonicity, concavity, and convexity of fractional derivative of some functions and derive corresponding criteria. Several examples are provided to illustrate the applications of our results. Fractional calculus is a generalization of the traditional integer order calculus. Recently, fractional differential equations have received increasing attention since behavior of many physical systems can be properly described as fractional differential systems. Most of the present works focused on the existence, uniqueness, and stability of solutions for fractional differential equations, controllability and observability for fractional differential systems, numerical methods for fractional dynamical systems, and so on see the monographs –4 and thIt is well known that the monotonicity, the concavity, and the convexity of a function play an important role in studying the sensitivity analysis for variational inequalities, variational inclusions, and complementarity. Since fractional derivative of a function is usually not an elementary function, its properties are more complicated than those of integer order derivative of the function. The focal point of this paper is to investigate the monotonicity, the concavity, and the convexity of fractional derivative of some functions.Now we recall some definitions and lemmas which will be used later. For more detail, see –4. a, b] of ℝ, the fractional order integral of a function f ∈ L1 of order α ∈ ℝ+ is defined byGiven an interval  can be written asRiemann-Liouville's derivative of order f is defined on the interval  and fn)((t) ∈ L1. The Caputo's fractional derivative of order α with lower limit a for f is defined asn − 1 < α ≤ n.Suppose that a function α ≤ 1, it holds thatParticularly, when 0 < α. Namely,Re(α) denotes the real parts of α.There exists a link between Riemann-Liouville and Caputo's fractional derivative of order α < 1, it holds thatParticularly, for 0 < f :  → ℝ with  ⊂ ℝ is said to be convex if whenever t1 ∈ , t2 ∈ , and θ ∈ , the inequalityA function RLDt0αf(t) and CDt0αf(t). Summarizing this paper forms the content of The rest of this paper is organized as follows. α < 1. The paper  and u(t0) ≥ 0, then the solutions u(t) of  of  are nonng) ≥ 0 and (d/dt)g) ≥ 0 on , then the solution u(t) of  of  is nondeg) ≤ 0 and (d/dt)g) ≤ 0 on , then the solution u(t) of  of  is not iAssume that 0 < tions of  exist.Ifg) ≥ 0, it holds that (1/Γ(α))∫t0t(t − s)α−1g)ds ≥ 0. Noting u(t0) ≥ 0, we have u(t) ≥ 0.The conclusion of (1) is obvious. In fact,  is equivd/dt)g) ≥ 0 on  and g) ≥ 0, thus t0, t1]. Hence u(t) is nondecreasing on , and (2) holds.Now we prove the validity of (2) and (3). First, by the definition of the Caputo's derivative, it holds from  that(10Similar to the proof of (2), we can prove that (3) holds. This completes the proof.g = λu, then (CDt0αu(t) = λu. The solution u(t) of CDt0αu(t) = λu isu(t0) ≥ 0, thenLemma  2.4 in  is a parλu, then  is CDtα < 1. Consider the fractional differential equationt > 0, we have t + sint ≥ 0 and (t + sint)′ = 1 − cost ≥ 0. By u(t) is nondecreasing in t for t ≥ 0. Assume that 0 < α < 1. Consider the fractional differential equationg) = −2, then g) < 0 and t ≥ t0. By f(t) is not increasing. In fact, by computation we get t0, ∞), thus f(t) is decreasing. Assume that 0 < The following fractional comparison principle is an improvement of Lemma  6.1 in  and Theoα < 1 and CDt0αf(t) ≥ CDt0αg(t) on interval . Suppose further that f(t0) ≥ g(t0), then f(t) ≥ g(t) on .Suppose that 0 < CDt0αf(t) − CDt0αg(t) = m(t), t ∈ . ThenIt0α on both sides of (m(t) ≥ 0, thus It0α(m(t)) ≥ 0. Then we havef(t) ≥ g(t) on , and the proof is completed.Set 1]. ThenCDt0α. Theorem  2.6 in  such that f(t0) ≤ 0, t0, t1], then RLDt0αf(t) is nondecreasing on ; f(t0) ≥ 0, t0, t1], then RLDt0αf(t) is not increasing on ; f(t0) > 0, t0, t1] and β ∈  such that RLDt0αf(t) is not increasing on  and is not decreasing on ; f(t0) < 0, η ∈  such that RLDt0αf(t) is nondecreasing on  and RLDt0αf(t) is not increasing on .Assume that 0 < d/dt)(RLDt0αf(t)) ≥ 0 on . Thus RLDt0αf(t) is nondecreasing on . By assumptions in (2), it follows that RLDt0αf(t) is not increasing in t on . Consequently, the conclusions of (1) and (2) are true.Using formula , we havef(t0) > 0 and t → t0. By the fact that δ1 > 0 such that (d/dt)(RLDt0αf(t)) ≤ 0 on . On the other hand, when β ∈  such that (d/dt)(RLDt0αf(t)) ≤ 0 on  and (d/dt)(RLDt0αf(t)) ≥ 0 on . Therefore, the conclusion of (3) is valid.Let us prove (3). Noting formula ,(24)ddtThe proof of (4) is similar to that of (3). This completes the proof. CDt0αf(t). Now we are to investigate the monotonicity of the function α < 1. If there exists an interval  such that t0, t1] and CDt0αf(t) is nondecreasing on . If t0, t1] and CDt0αf(t) is not increasing on . Assume that 0 < t0, t1] and d/dt)(CDt0αf(t)) ≥ 0 in t on . Hence, CDt0αf(t) is nondecreasing on interval . If d/dt)(CDt0αf(t)) ≤ 0. Hence, CDt0αf(t) is not increasing on . The proof is completed. Set The following examples illustrate applications of Theorems α < 1. Consider RLDt0αf(t), where f(t) = et, for all t0 ∈ ℝ. Since β > t0 such that RLDt0α(et) is decreasing on  and is increasing on . Since (sint)′′ ≤ 0 for t ∈  and (sint)′|t=π/2 = 0, by CDπ0.5αsint is decreasing on . By similar argument, CDπ1.5αsint is increasing on t ∈ . Since CDt0αsint = (1/Γ(1 − α))∫t0t(t − τ)α−cosτd, thus (1/Γ(1 − α))∫π0.5t(t − τ)α−cosτdτ is decreasing on  and (1/Γ(1 − α))∫π1.5t(t − τ)α−cosτdτ is increasing on t ∈ .Assume that 0 < α < 1. Consider CDt0αf(t); here t0 = 1 and f(t) = t − t2. Obviously, t ∈ , CDt0αf(t) is not increasing on .Assume that 0 < RLDt0αf(t) and CDt0αf(t). By formula  ≥ 0 on , f(t0) > 0, then RLDt0αf(t) is concave on . If f′′′(t) ≤ 0 on , f(t0) ≤ 0, then RLDt0αf(t) is convex on . Assume that 0 < CDt0αf(t). The next theorem is on the convexity and the concavity of α < 1. If there exists an interval  such that f′′′(t) ≥ 0 on , CDt0αf(t) is concave on . If f′′′(t) ≤ 0 on , CDt0αf(t) is convex on . Assume that 0 < f′′′(t) ≥ 0 on , d2/dt2)(CDt0αf(t)) ≥ 0 on . Hence, CDt0αf(t) is concave in t on . If f′′′(t) ≤ 0, on , d2/dt2)(CDt0αf(t)) ≤ 0 on . Therefore CDt0αf(t) is convex in t on . By formula , we haveα < 1. Consider the fractional differential equation CDt0αf(t); here t0 < 0 and f(t) = t − t2. Obviously, f′′′(t) = 0. For all t0 < 0, it holds that f′′′(t) = 0 on . Then by CDt0α(t − t2) is convex on . Assume that 0 < RLDt0αf(t), where f(t) = et, t0 ∈ ℝ. Obviously, Theorems RLDt0αet. Now we employ the method which is used in the proof of t ∈ . Thus (d2/dt2)(RLDt0αet) > 0 on  and (d2/dt2)(RLDt0αet) ≥ 0 on  and is concave on [β, +∞). Consider the concavity and convexity of the function proof of d2dt2 and CDt0αf(t). Based on the relation between the Riemann-Liouville fractional derivative and the Caputo's derivative, we obtain the criteria on the monotonicity, the concavity, and the convexity of the functions RLDt0αf(t) and CDt0αf(t). In the meantime, five examples are given to illustrate the applications of our criteria.The main part of this paper is to study the monotonicity, the concavity, and the convexity of the functions


Macleaya cordata extract is of great scientific and practical interest to researchers, due to its antimicrobial and anti-inflammatory responses within experimental animals. This study was designed to determine the diarrhea score and innate immunity of growing piglets after they had received Macleaya cordata extract supplements. A total of 240 growing pigs were randomly assigned to one of three dietary treatments, with 8 replicates per treatment and 10 piglets per replicate. All pigs received a basal diet containing similar amounts of nutrients. The three treatments were a control (no additive), an antibiotic (200 mg/kg colistin), and the Macleaya cordata extract supplement group (40 mg/kg Macleaya cordata extract). The diarrhea score was calculated after D 28. The jejunal samples were obtained from five piglets selected randomly from each treatment on D 28. In comparison with the control group, the dietary Macleaya cordata extract and colistin group demonstrated a substantially decreased diarrhea score. The introduction of Macleaya cordata extract supplements to the diet significantly increased volumes of ZO-1 and claudin-1, particularly in comparison with the pigs in the control group (P < 0.05). The findings indicate that Macleaya cordata extract does enhance intestinal barrier function in growing piglets and that it could be used as a viable substitute for antibiotics. In recent years, there has been an increased focus on reducing or eliminating the use subtherapeutic antibiotics within livestock diets. For this reason, there has been a concerted effort to identify alternative effective therapies that could serve as a substitute for antibiotics in pig diets. The aim is to maintain acceptable performance levels and ensure food safety for consumers . The medMacleaya cordata extract is believed to be an effective natural appetiser in swine, bovine, poultry, and even fish nutrition [ Macleaya cordata extract is blended from intact aerial parts and a fraction of quaternary benzo[c]phenanthridine alkaloids (QBAs), primarily sanguinarine (SG) and chelerythrine (CH), and standardised to 1.5% w/w SG phenanthridine alkaloid, is synthesised from dihydrosanguinarine, via the activities of dihydrobenzophenanthridine oxidase . It has  Fumaria varieties. It is a quaternary benzo[c]phenanthridine alkaloid. According to studies, it mostly exhibits tumour resistant, microbe resistant, and inflammation resistant qualities. Plus, the substance is a powerful disruptor when it comes to PKC (or protein kinase C). As such, the prospective utilisation of CHE, as a form of inflammation resistance, has been the topic of much debate. Its qualities are linked to its capacity to engage with DNA and proteins [Chelerythrine can be found within the greater celandine plant and a number of additional poppyproteins . This isproteins . Macleaya cordata extracts might stimulate the immune system and, as a consequence, decrease the incidence of diarrhea in growing piglets. Thus, the objective of the study was to evaluate the impact of Macleaya cordata extract, as a dietary supplement, on diarrhea scores and the expression of tight junction proteins.For this study, we hypothesised that dietary supplementation withAll of the procedures used in this study have been approved by the Institute of Subtropical Agriculture, the Chinese Academy of Sciences Animal Care and Use Committees. A total of 240 (Yorkshire × Landrace) × Duroc  pigs were obtained from a commercial swine herd in Guangdong, China. 240 piglets were assigned, in completely random design (but based on their BW), to 24 pens. The pens each contained a total of ten piglets. The process was carried out according to the experimental animal allotment program created by Kim et al. . All pen Macleaya cordata extract group . The Macleaya cordata extract was kindly provided by Phytobiotics Futterzusatzstoffe GmbH, Eltville, in Germany and Micolta Bioresource Inc., in Changsha, China. The pigs had unlimited access to feed and water throughout the entirety of the study.All piglets were fed the same basal diet, with a similar amount of nutrients . This diOn days 7, 21, and 28 of treatment, 10 mL of blood was collected in plastic uncoated tubes between 8:00 and 10:00 a.m. After collection, these blood samples were centrifuged at 8000 ×g for 10 min at 4°C, with sera collected and frozen at −20°C until further analyses.To evaluate diarrhea incidence, faecal consistency scores  were determined for each pen. These scores were collected by a trained individual, but who had no prior knowledge of the dietary treatments provided. The incidence of diarrhea was calculated by dividing the total number of pigs with diarrhea by the total number of all experimental pigs. The rate ratios were then calculated. On day 28 of the experiment, a number of the pigs (1 pig/pen) were killed. 1 sample of jejunal mucosa was collected in a sterile sample bag and stored at −20°C until analysis.γ-calculating instrument GC-300  was also used as part of this equipment. Recommendations from the maker were followed at all times.The serum volumes of IgM and IgG were calculated according to readings from the 1251 Radio Immunoassay Analysing tool . A The volume of serum D-lactate and DAO were calculated using Beckman Cx4 Chemistry Analyser  with a kit . Recommendations from the maker were followed at all times. All changes to or within the serum diamine oxidase were calculated with assay equipment.α (TNF-α) within serum was calculated via the use of a Porcine TNF-α Colorimetric ELISA tool . 50 μL of regular plus dilute solution (or 100 μL of the sample) was introduced to microplate wells. The wells had already been pretreated with capture antibody, as well as biotinylated antibody reagent. Identification relied on the utilisation of horseradish peroxidase, a stop solution of 0.18 N H2SO4, and TMB substrate. The identification parameter for TNF-α was 5 pg/mL. Merging was detected at 450 and 540 nm, with the use of the KC4 data evaluation programme and an ELISA plate tool.The proportion of tumour necrosis factor-β-actin functioned as an interior control because it expressed no dissimilarities across the populations. The significance of the protein display was represented by the ratio of the densitometry units of β-actin and tight junction protein. For a short time, all protein was removed, according to the advice provided by a protein removal tool . The mucosa proteins within the intestines were isolated with a polyacrylamide substance . They were then introduced to polyvinylidene difluoride membranes. These membranes were kept secure and protected for twelve hours, at a temperature of 4°C, after the introduction of the first antibodies. After the introduction of the secondary antibody, they were kept at 25°C, for 120 minutes. The first antibodies  were sourced from Santa Cruz Biotechnology . The secondary antibodies used were goat anti-rabbit IgG-HRP and rabbit anti-goat IgG-HRP .The tight junction protein displays of occludin, claudin-1, and zonula occludens-1 (ZO-1) were calculated with the use of western blotting. Western blot testing was carried out via the use of a sophisticated chemiluminescence identification tool . The results were captured with the ChemiScope 3400 device . They were evaluated with the use of Quantity One equipment . The To evaluate and verify the results, an analysis of variance (or ANOVA) method was used for basic classification and order of a completely randomized design. Before ANOVA, the evenness of its variance was checked using the Bartlett technique. Then, the regularity of the information was tested using the Kolmogorov-Smirnov method. At certain points, a Duncan multiple range method  was utilised to calculate dissimilarities across mean values. Macleaya cordata extract on the serum biochemical parameters and volume of antibodies in the growing pigs on days 7, 14, and 28 after the start of the study.P < 0.05) in pigs from the MC group, when compared with the other 2 groups. The serum concentrations of D-lactate, DAO, IgM, and TNF-α did not exhibit any substantial or notable differences (P > 0.05) across the treatments, on day 7 after the launch of the study.On day 7, the concentration of IgG was higher (P < 0.05) across the treatments. There was a lower concentration in pigs from the AB group. The other serum parameters for the pigs remained the same (P > 0.05), due to the impact of dietary supplementation with Macleaya cordata extract (P < 0.05). The other parameters exhibited no notable changes (P < 0.05), as a consequence of the experimental treatments.On day 14, the serum concentration of D-lactate was the only parameter that showed a significant difference ( extract . On day P < 0.05), in comparison with those in the NC and AB groups. Also, ZO-1 protein increased significantly (P < 0.05), in comparison with that of the NC group. Thus, the dietary supplementation of Macleaya cordata extract and antibiotics substantially increased the expression of Claudin-1 (P < 0.05), particularly when compared with that of the NC group. Escherichia coli and others pathogenic bacteria inside the gut after weaning. This leads to a loss of water and electrolytes, via the semiliquid faeces [Diarrheal syndrome occurs primarily because of an increase ind faeces . Accordid faeces  and Kongd faeces , the supAs Newton et al.  explain,There is a relationship between intestinal pH, microflora population, and diarrhea incidence in pigs . This is Macleaya cordata extract also has other important characteristics, such as its anti-inflammatory effect and immunomodulatory properties [ Macleaya cordata extract, provided as a natural supplement to growing pigs, could be a viable substitute for feed antibiotics.Crucially,operties , 8, 9, wP < 0.05) of IgG in pigs of MC group ), perhaps because of a higher immunological stability in the pigs. However, other studies on medicinal plant additives have shown a variability in the serum concentration of IgG in pigs [P < 0.05 = in pigs from MC group). IgM is the first to be synthesised, as a response to infection [ Macleaya cordata extract, we observed a healthy response in growing pigs (It should be noted that this serum antibody (IgG) did not increase ( in pigs , 17. Inting pigs . AccordiWhen it comes to sustaining and protecting the translocation of bacteria in the intestines, an undamaged intestinal barrier is very important. It stops allergenic and toxic substances from making their way inside the gut and becoming a danger , 20. D-Lβ-actin and occludin [ Macleaya cordata to the diet, as an additional supplement, boosts volumes of ZO-1 and Claudin-1 proteins.The intestinal barrier is tightly controlled by a carefully arranged piece of the epithelial junctional complex. It is usually called “the tight junction” . The poroccludin . It alsooccludin . For thi Macleaya cordata extracts to the diet, as an additional supplement, can increase resistance to intestinal damage, to some degree. This is achieved, throughout the growing stage, via increases in the volume and generation of claudin-1 and ZO-1. A number of earlier studies, on animals, had already made it clear that intestinal strength is closely linked to claudin-1 and ZO-1 volumes [ E. coli [The experiment shows that introducing volumes . Accordi volumes , fluctua E. coli . It happ E. coli . For all E. coli  and, eve Macleaya cordata extract supplements caused a reduction in faecal dysfunction. This result was underscored by larger volumes of claudin-1 and ZO-1. Consequently, the fortifying impact of Macleaya cordata supplements may be, to some degree, linked with the enhancement of intestinal barrier strength, particularly when it comes to treating conditions like diarrhea.To summarise, boosting the diet with


Keratin (K) 19-positive hepatocellular carcinoma (HCC) is well known to have a higher malignant potential than K19-negative HCC: However, the molecular mechanisms involved in K19-mediated progression of HCC remain unclear. We attempted to clarify whether K19 directly affects cell survival and invasiveness in association with cellular senescence or epithelial-mesenchymal transition (EMT) in K19-positive HCC.K19 in the human HCC cell lines, HepG2, HuH-7, and PLC/PRF/5. Finally, we investigated HCC invasion, proliferation, and angiogenesis using K19-positive HCC specimens.K19 expression was analysed in 136 HCC surgical specimens. The relationship of K19 with clinicopathological factors and survival was analysed. Further, the effect of K19 on cell proliferation, invasion, and angiogenesis was examined by silencing K19 silencing suppressed cell growth by inducting apoptosis or upregulating p16 and p27, resulting in cellular senescence. In addition, transfection with K19 siRNA upregulated E-cadherin gene expression, significantly inhibited the invasive capacity of the cells, downregulated angiogenesis-related molecules such as vasohibin-1 (VASH1) and fibroblast growth factor 1 (FGFR1), and upregulated vasohibin-2 (VASH2). K19-positive HCC specimens exhibited a high MIB-1 labelling index, decreased E-cadherin expression, and high microvessel density around cancer foci.Analysis of HCC surgical specimens revealed that K19-positive HCC exhibited higher invasiveness, metastatic potential, and poorer prognosis. In vitro experiments using the human HCC cell lines revealed that K19 directly promotes cancer cell survival, invasion, and angiogenesis, resulting in HCC progression and poor clinical outcome. K19 may therefore be a novel drug target for the treatment of K19-positive HCC.The online version of this article (doi:10.1186/s12885-016-2949-y) contains supplementary material, which is available to authorized users. Liver cancer is the second leading cause of cancer death in men worldwide. In 2012, the incidence of liver cancer was estimated at 782,500 and 745,500 deaths were associated with this disease . In prevThe mechanisms responsible for the increased malignancy of K19-positive HCC compared to conventional K19-negative HCC have been previously explored in the study by Govaere et al. . In the Tissue specimens were collected from 136 patients with HCC who underwent primary curative hepatectomy at the Nara Medical University Hospital, during the period between 2007 and 2012. No other treatments were given before resection. There were 103 men and 33 women with an age range of 29 to 84 (mean 69) years. Of the 136 HCC cases, 33 (24.3%) were positive for hepatitis B virus surface antigen (HBsAg), 62 (45.6%) were positive for hepatitis C virus antibody (HCVAb), and 43 (31.6%) were negative for both HBsAg and HCVAb. The follow-up period from surgical treatment until death due to HCC (16 cases) or the end of this study was 30 to 2550 days (mean 1100 days).Tissues were fixed in 10% formalin, embedded in paraffin, cut into 3 μm sections, and mounted on silane-coated slides. One section from each tissue was stained with hematoxylin and eosin for histological examination. The diagnosis of HCC was based on WHO criteria . RecurreImmunohistochemical study was performed on paraffin sections using a BOND MAX Automated Immunohistochemistry Vision Biosystem . For antigen retrieval step, Bond Epitope Retrieval Solution 1   was used. Antibodies for immunohistochemistry are listed in Table The human HCC cell lines, HepG2, HuH-7, and PLC/PRF/5 were purchased from Japanese Collection of Research Bioresources Cell Bank  and cultured in RPMI supplemented with 10% FBS.5 cells per well in 6-cm plates, and transfected with 100 nmol/L control RNA  or human K19 siRNAs using Lipofectamine RNAiMAX , in accordance with the manufacturer's protocol. After culturing for the indicated time, the samples were removed and homogenized.The cells were seeded at 10Template cDNA was synthesised from 1 μg of total RNA using Primer Script RT reagent Kit . The quantitative real-time PCR detection was performed using a SYBR® Premix Ex Taq kit (Takara). The amount of actin mRNA in each sample was used to standardise the quantity of each mRNA. The sequences of the primers used for PCR are shown in Table For the cell proliferation assay, the methane thiosulfonate (MTS) reagent was used as previously described –14. All In vitro invasion assays were performed using Matrigel invasion chambers  as previously described . InvadinCells were fixed at 70% confluence and then incubated at 37 °C overnight with staining solution containing X-gal substrate . Cells were then observed under a microscope for the presence of blue stain .Liquid based cytology (LBC) was used to prepare the cell lines for apoptosis assay by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labelling (TUNEL) using the ApopTag in situ apoptosis detection kit  . We idenp < 0.05.Differences in continuous variables were analysed using ANOVA or nonparametric tests . All the experimental results were analysed using the 1-way analysis of variance and Tukey’s post-hoc test. The 2-tailed student’s t-test was used to compare 2 data points. The survival curves were calculated by the Kaplan-Meier method, and the differences between curves were analysed by the log-rank test. Multivariate analysis for overall survival was performed using a Cox regression model with forward stepwise selection. The results were considered to be statistically significant if p = 0.002). Among the organs, metastasis to lung was most frequently observed in this study (p = 0.003). There was no significant difference between K19 expression and HBV or HCV infection. The non-HBV/non-HCV group and other pathological parameters such as microvascular invasion and fibrous stroma were not statistically correlated with K19 expression.Out of the total 136 HCC cases, 12 K19-positive HCC cases (8.8%) were examined in the present study Fig. . Resultsp < 0.01)  unless the data were analysed during an early phase  Fig. . In contase Fig. . The mulK19 expression was successfully suppressed by transfection with K19 siRNA, followed by 72-h incubation   Fig. . In cont01) Fig. . The Ki-01) Fig. . These pIn the current study, we demonstrated that K19 promoted HCC invasion, proliferation, and angiogenesis, using in vitro experiments and immunohistochemistry. Survival analysis revealed that patients with K19-positive HCC had significantly poorer overall survival than did patients with K19-negative HCC, although K19 expression was not an independent predictor in the multivariate analysis for overall survival. In previous reports, K19-positive HCC demonstrated higher invasiveness, greater metastatic potential, and poorer prognosis than did conventional HCC. Moreover, K19-positive HCC specimens examined had greater vessel invasion, poor differentiation, greater infiltrative growth, and more extrahepatic metastasis than did K19-negative HCC specimens , 8. AlthK19 knockout mice were viable, fertile, and appear normal [The keratins, which are intermediate filament proteins, play several important roles within the cell. For instance, they maintain the mechanical stability and integrity of epithelial cells, as well as participate in several intracellular signalling pathways involved in coping with cell stress . K19 is r normal . In the p53, p16INK4a and p15INK4. p16 is well known to induce cell quiescence, which is tightly associated with cell differentiation. Thus, K19 could inhibit HCC cell differentiation by regulating p16. Apoptosis was induced by K19 knockdown in vitro; however, the TUNEL assay did not indicate a significant difference in apoptosis induction between K19-positive and K19-negative HCC areas. The percentage of Ki-67-positive cells was statistically higher in K19-positive HCC areas than in K19-negative areas. Considered together with the in vitro data, K19 appears to promote HCC cell proliferation, and its suppression effectively inhibits tumour growth via induction of cytotoxicity.Ozturk et al.  reportedK19 knockdown in HCC cell line resulted in reduced invasive ability. We found that K19 promotes cancer invasion in HepG2 cells through the downregulation of E-cadherin gene expression. Gene expression of snail, N-cadherin, and vimentin was not affected by K19 knockdown. Kim et al. [Recently, Govaere et al.  reportedm et al.  reportedm et al. . The mecK19 upregulated FGFR1 and VASH1 and downregulated VASH2 in HCC cells. Moreover, immunochemical analysis showed increased blood vessels in K19-positive HCC. FGFR1 is a receptor tyrosine kinase that activates endothelial-cell proliferation and migration [K19 may enhance tumour angiogenesis by regulating FGFR1, VASH1, and VASH2 in HCC. Yoneda et al. [We showed here that igration . Thus, iigration . Recent igration , 26. Sevigration , 28. VASa et al.  reportedK19 enhanced angiogenesis by affecting the expression of angiogenesis-related genes such as VASH1, VASH2, and FGFR1. Thus, K19 directly promotes cancer cell survival, invasion, and angiogenesis. K19 could be a new target molecule for the development of therapies against K19-positive HCC.Our findings clearly indicate that K19 has a direct role in promoting HCC cell survival and invasion by inhibiting senescence and apoptosis and downregulating E-cadherin gene expression, respectively. In addition,


Neglected for several decades, nutrition is now firmly on the development agenda. Important landmarks are the initiation of the Scaling Up Nutrition movement in 2010; the adoption by the World Health Assembly of the Comprehensive Implementation Plan for Maternal, Infant and Young Child Nutrition in 2014; and the World Health Organization’s (WHO) Global Action Plan for the Prevention and Control of Noncommunicable Diseases for 2013–2020. Public health nutrition has to meet multiple new challenges, including the shift from the millennium development goals to the sustainable development goals (SDGs), together with growing issues such as climate change, globalization, urbanization, socioeconomic disparities, migration and wars.http://wphna.org), and a full report has been published elsewhere.Despite some progress, efforts to alleviate malnutrition, whether under- or overnutrition, are hampered by countries’ lack of capacity in public health nutrition, including an insufficient and poorly qualified workforce. This paper highlights current issues and challenges in public health nutrition in low- and middle-income countries and shares recommendations for the development of this workforce. It is primarily based on the work of the World Public Health Nutrition Association capacity-building taskforce, while also drawing on relevant data from published material. Background documents are available on the Association’s website  within their meagre health workforce expenditures. The complexity of nutrition as a discipline and practice tends to be overlooked; doctors, nurses and community health workers need specific preparationAnother issue is that in lower-income countries undernutrition is a higher priority for interventions than nutrition-related chronic diseases. The latter are currently escalating in these countries. Both food system changes, at the level of production, processing and distribution, and behaviour change communication are needed to reorient the nutrition transition, and nutritionists have a major role to play in this regard. Studies on nutrition workforce capacity conducted in West Africa confirm this, and also highlighted the severe shortage of trained nutrition professionals (except in Nigeria and Ghana).How can we build this public health nutrition workforce? Several initiatives have been taken to assess and strengthen the capacity of nutrition workforces. However, substantive action is still needed with the support of WHO and other actors, as shown in the recommendations . The IntBox 1More nutritionists need to be trained at the undergraduate level to carry out the bulk of nutrition intervention work.A core of specialized nutritionists qualified in public health nutrition at masters level needs to be formed in every country to work at national and district levels.More and up-to-date public health nutrition has to be integrated into the curriculum of medical and nursing studies, as well as in the training programmes of nutritionists.In-service training in nutrition and in the management of nutrition programmes is required for scaling-up nutrition efforts. This calls for initial in-service training of available staff, supervisors and trainers.Hybrid training programmes, which combine distance training and periodic in-person sessions with tutors and peers, are a cost-effective approach for pre-service and in-service training as well as for continuous education of nutrition professionals.Competency standards for nutrition job descriptions, and curricula and accreditation schemes, should be developed and harmonized at the regional level, with international support.Development of a national nutrition workforce should be an integral component of national nutrition and workforce development plans, with adequate funding secured by governments and other relevant actors including nongovernmental organizations.The nutrition workforce is best portrayed as a pyramid, representing the numbers, level of training and occupational profiles at various levels . The basAlthough it requires sustained efforts, training can be regarded as the easy part of nutrition workforce development in low- and middle-income countries. The core technical and horizontal skills that public health nutritionists (masters level) need to acquire in the areas of intervention management, capacity-building and research have been proposed, along with assessment indicators.The underlying causes of malnutrition, and hence sustained solutions to the problem, lie to a large extent in the non-health sectors. Nutrition therefore has to be addressed not only by other health professionals, but also by agriculture and education professionals and field workers, who need to integrate relevant nutrition tasks into their professional activities (such as orienting food production towards meeting the population’s nutrition requirements or teaching healthy eating to schoolchildren;


The provision of nutrition care by doctors is important in promoting healthy dietary habits, and such interventions can lead to reductions in disease morbidity, mortality, and medical costs. However, medical students and doctors report inadequate nutrition education and preparedness during their training at school. Previous studies investigating the inadequacy of nutrition education have not sufficiently evaluated the perspectives of students. In this study, students’ perspectives on doctors’ role in nutrition care, perceived barriers, and strategies to improve nutrition educational experiences are explored.A total of 23 undergraduate clinical level medical students at the 5th to final year in the School of Medicine and Health Sciences of the University for Development Studies in Ghana were purposefully selected to participate in semi-structured individual interviews. Students expressed their opinions and experiences regarding the inadequacy of nutrition education in the curriculum. Each interview was audio-recorded and later transcribed verbatim. Using the constant comparison method, key themes were identified from the data and analysis was done simultaneously with data collection.Students opined that doctors have an important role to play in providing nutrition care to their patients. However, they felt their nutrition education was inadequate due to lack of priority for nutrition education, lack of faculty to provide nutrition education, poor application of nutrition science to clinical practice and poor collaboration with nutrition professionals. Students opined that their nutrition educational experiences will be improved if the following strategies were implemented: adoption of innovative teaching and learning strategies, early and comprehensive incorporation of nutrition as a theme throughout the curriculum, increasing awareness on the importance of nutrition education, reviewing and revision of the curriculum to incorporate nutrition, and involving nutrition/dietician specialists in medical education.Though students considered nutrition care as an important role for doctors they felt incapacitated by non-prioritisation of nutrition education, lack of faculty for teaching of nutrition education, poor application of nutrition science and poor collaboration with nutrition professionals. Incorporation of nutrition as a theme in medical education, improving collaboration, advocacy and creating enabling environments for nutrition education could address some of the barriers to nutrition education. There is ample evidence that nutrition interventions can decrease morbidity, mortality, human suffering, and medical costs –4. GivenIndeed, there is an unfilled role for medical education in preparing doctors to provide nutrition care to patients . SeveralSeveral barriers to inadequate nutrition education have been reported largely in the form of symposiums, commentaries, essays and special articles , 22–25. This is an important issue to investigate, as students are likely to bring unique and valuable perspectives on the inadequacy of nutrition education in their curriculum. Their views should be considered in efforts to improve nutrition education in the medical curriculum.What are the roles of doctors in the provision of nutrition care in the general practice setting?Why is nutrition education inadequate in the medical curriculum?How could nutrition education be improved in the medical curriculum?The study therefore aimed to explore students’ perceptions of doctors’ role in nutrition care, and barriers that prevent effective nutrition education and strategies that could potentially increase the effectiveness of nutrition education in the medical curriculum. The following research questions were investigatedOur research was informed by two closely related theories : social Our research is within the constructivists’ research paradigm. In constructivism, knowledge is socially constructed and realities are generated by the interaction of social, cultural and interpersonal factors , 33. AccWe adopted a purposive sampling to select the study participants. All participants were selected from the University for Development Studies, School of Medicine and Health Sciences (UDS-SMHS), which runs a problem-based undergraduate medical curriculum. In the first 3 years, students are taken through the basic sciences using system-based blocks. The next year focuses on the learning of pathology and patho-physiology of diseases. Although students have some early patient encounters, the first 4 years are usually non-clinical . In preparing students to qualify as doctors, the remaining 3 years focus on the clinical application of principles learned in the preclinical years and the creation of opportunities for students to learn from real patients at the hospital through departmental clinical rotations. The UDS-SMHS also runs a community-based education and service (COBES) programme in which students live, learn and provide service in rural communities of Ghana for a period of 4 weeks per year during year 2 to 4. It is during the preclinical years that majority of nutrition education is learned.Our participants were therefore clinical level students, who had covered over 50% of the curriculum. Our choice of participants and sampling procedure was informed by our aim to select participants who will provide rich information , 37 regaVM contacted all prospective participants through face-to-face meetings after usual lectures. During such meetings, the purpose of the study was explained and participants were also informed that the interview will be audio-recorded. They were assured of the confidentiality of the recordings. Participation was voluntary and both written and verbal informed consent was obtained from all participants who agreed to participate in the study. The institutional review board of the Navrongo Health Research Institute approved the research protocol.All data was collected using semi-structured individual interviews. Semi-structured interviews are frequently used in healthcare and provide the researcher the opportunity to have guidance on areas to explore while allowing for some flexibility to enable discovery or elaboration , 39. AllThe questions were evaluated by all members of the team who have varying levels of experience in qualitative research, medical education and nutrition. We pilot tested the semi-structured interviews on a group of 8 students to ensure clarity and understanding of the questions. During this process participants provided feedback regarding the structure of the questions and also identified areas that needed clarification. AA observed these pilot interview sessions, providing the opportunity to train and give feedback. The data generated from the pilot sessions were not included into the main data analysis.All interviews were transcribed verbatim without identifying information by a trained research assistant, and entered into MAXQDA (version 12), a qualitative data analysis software. All subsequent data analyses were conducted using a comparative strategy , 42. CodTwenty-three students participated in semi-structured interviews lasting 10 to 20 min each during the study period, July to September, 2015. This number was arrived at after the point of saturation and further data collection and/or analysis was unnecessary. Table Four main themes emerged from the data: role of doctors in nutrition care, adequacy of nutrition education, barriers to nutrition education, and strategies to increase and improve nutrition education. Illustrative quotes are provided to substantiate each of these themes. Statements represent the views of students and not the authors.The majority of the students felt that doctors had an important role to play in providing nutrition care to patients although they recognised that nutritionists and dieticians were trained to perform such functions. They considered the role of the doctor to be one that is supportive or complementary to that of the nutritionist/dietician. The main roles identified by the students are shown in list 1.List 1: Roles doctors could play in nutrition careNutrition advice/educationSupporting patients to follow healthful dietsCollaborating with nutritionists/dieticiansMonitoring progress of nutrition careNutrition diagnosisReferring patients to nutritionistsAdvocating for nutrition care“They [doctors] should also play a part in the health education of the patient. So when they see a patient of any kind they have to advise them on their nutrition, diet and other behaviours that affect their nutrition and all of that.”Students believed that the doctor should be the first to provide basic nutrition care and refer the patient to a nutritionist/dietician for specialised care if need be.“When they [patients] come to the hospital, the doctor has the first encounter with them. The doctor could begin to provide nutrition care based on his/her minimal knowledge in nutrition. Then afterwards if he/she sees that there is still more to be done, then he/she can refer the patient to the nutritionist or the dietician who are specially trained to provide nutrition care.”In order to assess whether medical students considered themselves to be responsible for the nutrition care of their patients when they become doctors, they were asked a hypothetical question about how they will react if a diabetic patient sought dietary advice from them in the general practice setting. All of the students said they will feel obligated and enthusiastic to provide such dietary advice to the patient.“Oh I will feel happy to assist the patient. As such I will tell the patient the causes of diabetes and what to do to avoid [prevent] it. I will advise the patient to avoid excessive intake of sugar.”“Well I think it is the right thing to find out how they [patients] manage their nutrition based on their condition. But looking at the kind of training that we [students] also have, you realize that much attention is not given to nutrition. So if a patient should ask me at this moment about nutritional status or let’s say about their nutritional situation, I might not feel adequate enough to answer.”In addition, almost all the students considered the quality and quantity of their nutrition education to be inadequate.Although students felt that nutrition care was important and felt obligated to provide it to patients, majority of them felt unconfident in their ability to provide such care to their patients.“For me I think… even though we have done something very little concerning nutrition, it is as if we [students] have not done anything. We [students] have been given very little training when it comes to nutrition.”It is thus unsurprising that students felt they required further education in nutrition although they were in the senior years of their medical education.“I think there is more to be done because we [students] have not really had more lectures on it. We [students] have not been taken through a lot on nutrition; it is just a little bit of everything like small, small, small. So I think it would be better if we [students] are given more education on nutrition before we are able to come out.”In order to gain more knowledge and skills in nutrition some students undertook self-directed learning and also consulted nutrition departments at the hospital on their own volition to acquire knowledge and skills in nutrition care.“Because we [students] realized that our nutrition education was inadequate, when we [students] came here we had to go to the nutrition department to kind of like talk to them to take us through how they managed their [nutrition department] malnutrition cases”.Students identified a number of barriers contributing to the inadequacy in their nutrition education. These barriers were classified into three subthemes: personal, interpersonal and environmental barriers as shown in Table Most students felt that the application of nutrition science to clinical practice was poor in most of the already limited nutrition lectures they received, especially during their preclinical training. The apparent lack of application of nutrition science to clinical practice made it difficult for them to appreciate the relationship between nutrition and health and to apply nutrition during their clinical training.“Though at the preclinical level we [students] were given a little bit knowledge about nutrition it was not practical. It was like kind of raw information. You come here [clinical training] then you realize that there is no correlation. Not correlation as such but here [clinical training] you realize that it demands you to apply.”“the practical aspect of nutrition education has not really been taught or we are not exposed to it”.Another student adds that Another important barrier identified by the students was the perception of faculty and curricula planners that nutrition care may not be the responsibility of doctors and as such did not see the need to include adequate content of nutrition education into the curriculum. According to the students, faculty and curricula planners considered nutrition care to be the role of nutritionists and thus the medical curriculum should concentrate on how to treat diseases.“May be the authorities’ feel it’s not an essential part of medical training. I don’t know but that is the way I see it”.“May be the focus of the whole medical training is more on treating diseases.”“I think because there are nutritionist who are specially trained to provide nutrition care”.Students were concerned that their nutrition education did not involve nutrition professionals thus presenting limited opportunities to collaborate to learn about nutrition. The poor collaboration made it difficult for them to appreciate the role of nutrition care in improving the clinical outcomes of patients and also do not foster inter-professional training to promote multidisciplinary care required in patient care.“If there can be more integration. For instance when we [students] have cases that are nutrition related, it is still being managed by medical professionals and doctors. I mean once in a while dieticians come but it is like off record or something. So if those who are directly involved in the nutrition sector can be integrated more. May be it will help. But right now they are separated, nutrition is on one side and medicine is on the other. So maybe if there is a problem that will be the area it is.”Students identified that nutrition professional were not involved in their training because they were not available i.e. they were in short supply.Majority of the students felt that the medical curriculum concentrates largely on anatomy, physiology and pathology with a little attention for nutrition. The students felt strongly that nutrition has not been given the needed attention and priority that it deserved.“Like we have anatomy, physiology and the other basic sciences incorporated, we don’t actually have a course on nutrition incorporated into the courses that we do. I think that is the major issue”.“It’s also because nutrition is not a priority in the medical program and hence have been given less attention.”According to the students, the lack of priority for nutrition education has resulted in the limited contact hours allocated for nutrition, inadequate content for nutrition in the medical curriculum and poor integration of nutrition education as a theme throughout the entire medical curriculum.Students were also concerned about the lack of trained faculty to provide nutrition education.“May be it could also be that we don’t have the people around to actually, I mean teach us or take us through nutrition.”“I think sometimes the lecturers may not be available to give a lecture on that [nutrition].”A number of students also felt that faculty does not have the needed knowledge and skills to provide students with the required nutrition education.“May be I think it is….Because those taking you, they themselves they don’t have the clinical knowledge. It is like they just read raw nutrition [theoretical aspect of nutrition] and that’s how they also passed it on to you.”Having recognized the inadequacy of their nutrition education and the contributing barriers, students provided several important and insightful recommendations that could improve nutrition education.To increase the contact hours and nutrition content in the curriculum students suggested that more lecture topics on nutrition should be included into the curriculum.“Not really as in a full course but may be some few lectures in nutrition. I don’t think we need so much but some few things that you need on the job that to help you, that is very important. I think that aspect could be incorporated into the training, it will help.”Others also suggested that nutrition training could be improved by incorporating nutrition topics into their tutorials to promote self-directed learning.“I think that we can also introduce them into our tutorial topics because sometimes for most of the students tutorials really help. You read a lot before you come so you can introduce some of them into our tutorial topics”.Concerning the promotion of self-directed learning and to cater for the overcrowded curriculum, students suggested that articles on nutrition could be given to them to read to promote their understanding of nutrition concepts. The self-study time for students could also be increased to grant students the opportunity to read further on nutrition. In addition, students suggested the organization of symposiums on nutrition in which research papers in nutrition could be presented in order to increase their interest and understanding of nutrition.“Well it’s very dicey because there is time issue and stuff. But if we could get articles or make symposiums where we can teach nutrition courses and make it lively because nutrition is kind of like difficult. So if we make it motivational they will be able to come out and get the knowledge about nutrition so that they can educate the people.”As evidenced by the following code, students felt that their knowledge and skills in nutrition could be improved if nutrition as a theme was incorporated early in their training and maintained throughout the entire curriculum.“Looking at the early [preclinical] aspect of the training, they can incorporate nutrition subjects there, nutritional modules or topics and things like that especially at the very early aspects of it. So that people [students] will take interest in that and probably might grow their knowledge as they go along the PBL training.”Some students opined that nutrition education will be improved if those in charge were educated on the importance and need for nutrition education. Students believed that if faculty and curriculum planners could be convinced of the fact that nutrition is an important role of the doctor, this might change their perception regarding nutrition and increase attention and priority for nutrition. An increase in attention and priority for nutrition education may result in an increase in the content and contact hours for nutrition.“I think if they can realize that it is also very very important then they can increase the amount of time that is spent on that [nutrition education]”.Students believed that for nutrition education to be improved there is the need for faculty and curriculum planners to review the entire curriculum to identify students nutrition educational needs and how and where those needs could be met and incorporated into the curriculum. Students recognised that such revisions could not be effected during their time in the medical school but could be beneficial to those in the succeeding years in medical school.“That is what I previously stated that they should revise our curriculum and find a place to put nutrition so that at least we [students] will have knowledge about it. At least at this level I should have had enough knowledge about nutrition. So if they put it there those following us can benefit. Right now if they can add it to our curriculum, I think it will be enough.”Clinical sessions in which nutritionists/dieticians will present nutrition casesOpportunities to consult nutritionist/dieticians for relevant nutrition topics/contentIncluding the nutrition department into clinical rotationsSeminars and lectures presented by nutritionists/dieticiansStudents opined that nutritionists or dieticians should be actively involved in their training. This should take the following forms:“It [nutrition education] should be added to the medical school’s curriculum and we [students] should actually...ehmm if they have a nutrition department, we should actually be exposed to nutrition” “Even in the hospital we [students] can have nutritionist being involved in our training on the ward especially when we [students] are managing patients so that we can have more time with the nutritionist”.Undergraduate clinical level medical students believed medical doctors have a responsibility to provide nutrition care to their patients in the general practice setting. They believe doctors’ role regarding nutrition care should be one of identifying patients in need of nutrition care, providing first line nutrition management, advocating nutrition care for patients, referring patients to nutritionists/dieticians for specialist care and reinforcing nutrition care provided by nutritionists/dieticians. These students felt their current nutrition education was inadequate due to barriers such as lack of priority for nutrition education, poor application of nutrition to clinical practice, an already overcrowded medical curriculum, lack of faculty trained in nutrition and poor collaboration with nutrition professionals in the teaching and learning of nutrition. Students recognised the need to increase awareness on the relevance and need for nutrition education in the medical curriculum among faculty and curriculum planners and to undertake a revision of the medical curriculum to identify nutrition educational needs and avenues to meet such needs as well as recognising the need to involve nutritionists/dieticians in their training.Student’s views that medical doctors have an important role to play regarding nutrition care are similar to those expressed by medical educators, practicing doctors , 44 and Consistent with previous findings, students were concerned that their nutrition education was inadequate , 45–50.Although an already overcrowded curriculum and inadequate contact hours/content for nutrition education were frequently described as barriers to effective nutrition education, some of the students believed that this was more an issue of low priority and attention for nutrition education. According to these students if nutrition was considered an important responsibility of the medical doctor, faculty and curriculum planners will find avenues within the curriculum to include nutrition. There is thus the need to increase faculty and curriculum planners’ awareness on the relevance and need for nutrition education in the medical curriculum.Students’ suggestion of integrating nutrition as a theme throughout the entire curriculum to cater for barriers such as inadequate contact hours/content for nutrition and overcrowded curriculum is consistent with best practices for improving nutrition education , 51. IntFundamental to the feasibility of integrating nutrition as a theme throughout the medical curriculum is the need to undertake a review of the entire curriculum. This provides opportunities to look into the formal and informal/hidden curriculum to identify gaps and avenues to integrate nutrition education and improve the learning environment , 54.Given that multidisciplinary teaching is a key focus of education guidelines for future health professionals  it is coThe students suggestion of providing them with nutrition articles and the organisation of nutrition symposiums and seminars to address the barriers of overcrowded and inadequate curriculum are widely accepted innovative teaching and learning strategies of improving nutrition education , 61. TheThe lack of faculty for nutrition education is an important barrier that has been identified in previous findings , 8, 24. This is the first study to qualitatively explore students’ perceptions of nutrition education, barriers and strategies as far as we know. It adds to the existing literature that nutrition education is inadequate and several barriers are contributing to the current situation. Also, the findings identify a number of strategies that could be relied upon to improve nutrition education. An important novelty of the methods of this study is the reliance on students’ perspectives that hitherto may not be considered as obvious sources of information regarding this topic. The students provided important barriers and strategies that are comparable to those reported by medical educators and practicing doctors. It is yet additional evidence supporting the widely accepted recognition of students as important stakeholders of the curriculum who could be relied upon to improve the learning environment.This study is not without limitations. Our adoption of non-probability and convenience sampling may result in the recruitment of students with an interest in nutrition, generating a potential source of sampling bias. However, this potential bias can be described as a strength rather than a limitation in qualitative research that propagates for the collection of data from individuals considered as rich sources of information . We recrThe findings of this study provide data that could inform the planning and design of educational interventions to improve nutrition education. Future studies should investigate whether the removal of the identified barriers could result in improved nutrition education. It will be important for studies to evaluate the effectiveness of the strategies suggested by the students to improve nutrition education in the medical curriculum. In addition, future studies should investigate the influence of improved nutrition education on nutrition practice behaviour in the clinical setting.Students perceived nutrition care to be an important role and responsibility of medical doctors. They considered their current nutrition education to be inadequate due to personal, interpersonal and environmental barriers. A number of important strategies have been suggested by these students including incorporation of nutrition as a theme in the medical curriculum, collaboration, and advocacy and creating enabling environments for nutrition education.